Basic Information
| Provider Information | |||||||||
| NPI: | 1669840740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | JOHNNY | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6542 RUSTIC RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484394956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6012 SOUTH LINDEN ROAD | ||||||||
| Address2: | UNIT 15 MONTICELLO CENTER | ||||||||
| City: | SWARTZ CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484738889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106558244 | ||||||||
| FaxNumber: | 8106552192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501017308 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.